Behavior matters

Cognitive Behavioral Therapy for Chronic Pelvic Pain: What Is It and Does It Work?

PURPOSE

Urologic chronic pelvic pain syndrome (UCPPS), which encompasses interstitial cystitis/bladder pain syndrome in women and men and chronic prostatitis/chronic pelvic pain syndrome in men, is a common, often disabling urological disorder that is neither well understood nor satisfactorily treated with medical treatments. The past 25 years have seen the development and validation of a number of behavioral pain treatments, of which cognitive behavioral therapy (CBT) is arguably the most effective. CBT combines strategies of behavior therapy, which teaches patients more effective ways of behaving, and cognitive therapy, which focuses on correcting faulty thinking patterns. As a skills-based treatment, CBT emphasizes "unlearning" maladaptive behaviors and thoughts, and replacing them with more adaptive ones that support symptom self-management.

MATERIALS AND METHODS

This review describes the rationale, technical procedures, and empirical basis of CBT.

RESULTS

While evidence supports CBT for treatment-refractory chronic pain disorders, there is limited understanding of why or how CBT might work, for whom it is most beneficial, or the specific UCPPS symptoms (eg, pain, urinary symptoms) it effectively targets. This is the focus of EPPIC (Easing Pelvic Pain Interventions Clinical Research Program), a landmark NIH trial examining the efficacy of low-intensity, home-based CBT for UCPPS relative to a nonspecific comparator featuring self-care recommendations of AUA guidelines.

CONCLUSIONS

Systematic efforts to increase both the efficiency of CBT and the way it is delivered (eg, home-based treatments) are critical to scaling up CBT, optimizing its therapeutic potential, and reducing the public health burden of UCPPS.

The development of a novel sexual health promotion intervention for young people with mental ill-health: the PROSPEct project

BACKGROUND

Young people with mental ill-health experience higher rates of high-risk sexual behaviour, have poorer sexual health outcomes, and lower satisfaction with their sexual wellbeing compared to their peers. Ensuring good sexual health in this cohort is a public health concern, but best practice intervention in the area remains under-researched. This study aimed to co-design a novel intervention to address the sexual health needs of young people with mental ill-health to test its effectiveness in a future trial undertaken in youth mental health services in Melbourne, Australia.

METHODS

We followed the 2022 Medical Research Council (MRC) guidelines for developing and evaluating complex interventions. This involved synthesising evidence from the 'top down' (published evidence) and 'bottom up' (stakeholder views). We combined systematic review findings with data elicited from qualitative interviews and focus groups with young people, carers, and clinicians and identified critical cultural issues to inform the development of our intervention.

RESULTS

Existing evidence in the field of sexual health in youth mental health was limited but suggested the need to address sexual wellbeing as a concept broader than an absence of negative health outcomes. The Information-Motivation-Belief (IMB) model was chosen as the theoretical Framework on which to base the intervention. Interviews/focus groups were conducted with 29 stakeholders (18 clinicians, three carers, and eight young people). Synthesis of the evidence gathered resulted in the co-design of a novel intervention consisting of an initial consultation and four 60-90-minute sessions delivered individually by a young 'sex-positive' clinician with additional training in sexual health. Barriers and supports to intervention success were also identified.

CONCLUSIONS

Using the MRC Framework has guided the co-design of a potentially promising intervention that addresses the sexual health needs of young people with mental ill-health. The next step is to test the intervention in a one-arm feasibility trial.

Community Engagement in Behavioral Medicine: A Scoping Review

BACKGROUND

Behavioral medicine has made key contributions toward improving health outcomes. Engaging community partners in research is critical to addressing persistent health inequities. The aim of this scoping review was to explore how researchers engaged community partners within the field of behavioral medicine research from 2005 to 2023.

METHOD

Publication databases and gray literature were searched for research that engaged community partners to address questions relevant to behavioral medicine. Articles were screened by title and abstract, and then by full text. Articles meeting the inclusion criteria were coded using the framework provided by the Engagement Navigator to identify engagement approaches, methods, and tools and when they were used during the research.

RESULTS

Of 1486 articles initially identified, 58 met the inclusion criteria. Most articles used well-known approaches (e.g., community-based participatory research; 67%), methods (e.g., advisory committees; 59%), and tools (e.g., interviews; 41%), and engaged with healthcare service providers (62%) and/or patients (53%). Community partners were most often included in research planning and design (79%), and less often in dissemination (45%).

CONCLUSION

Community engagement has considerable potential to address health inequities. Our assessment of the approaches, methods, and tools used by behavioral medicine researchers to engage with a diverse range of community partners points toward promising strategies for enhancing the impact of community engagement. Researchers should incorporate explicit descriptions of community engagement strategies in publications, an outcome that could be facilitated by clear publishing guidelines, structured reporting tools, and clear messaging from funders about the value of community engagement in behavioral medicine research.

The relaxation zone: Initial analysis of stress management services for university students

Objective: We evaluated the Relaxation Zone (RZ), a room with "relaxation stations" designed to reduce stress in college students. Participants: Participants (N = 994) were enrolled during the 2019 calendar year. Most participants were female (62.8%), freshmen (59.3%), and African American (44.9%). Methods: Students visiting the RZ completed a brief pretest and posttest that measured self-reported stress. Results: Paired sample t-tests across class groups (e.g., freshman, sophomore) revealed a significant reduction in stress from pretest (Mpooled = 6.0) to posttest (Mpooled = 4.5), with medium to large effect sizes (Cohen's d ranging from 0.53 to 0.88) during their first visit. For students having at least two visits (N = 348), an exploratory dose-response analysis demonstrated that an optimal dose of self-guided relaxation ranged from two to eight visits. Conclusions: These findings provide initial evidence that programs like the RZ can reduce student stress within a few visits.

Implementation strategies preferred by primary care clinicians to facilitate cancer prevention and control activities

Key clinical and community members need to be involved in the identification of feasible and impactful implementation strategies for translation of evidence-based interventions into practice. While a wide range of implementation strategies has been developed, there is little research on their applicability for cancer prevention and control (CPC) efforts in primary care. We conducted a survey of primary care physicians to identify implementation strategies they perceive as most feasible and impactful. The survey included both primary prevention behavior change counseling and cancer screening issues. Analyses contrasted ratings of feasibility and impact of nine implementation strategies, and among clinicians in different settings with a focus on comparisons between clinicians in rural vs. non-rural settings. We recruited a convenience sample of 326 respondents from a wide range of practice types from four practice-based research networks in 49 states and including 177 clinicians in rural settings. Ratings of impact were somewhat higher than those for feasibility. Few of the nine implementation strategies were high on both impact and feasibility. Only 'adapting to my practice' was rated higher than a 4 ("moderate") on both impact and feasibility. There were relatively few differences between rural and non-rural clinicians or associated with other clinician or setting characteristics. There is considerable variability in perceived impact and feasibility of implementation strategies for CPC activities among family medicine clinicians. It is important to assess both feasibility and impact of implementation strategies as well as their generalizability across settings. Our results suggest that optimal strategies to implement evidence-based CPC activities will likely need to be adapted for primary care settings. Future research is needed to replicate these findings and identify practical, implementation partner informed implementation strategies.

Development and Integration of Machine Learning Algorithm to Identify Peripheral Arterial Disease: Multistakeholder Qualitative Study

BACKGROUND

Machine learning (ML)-driven clinical decision support (CDS) continues to draw wide interest and investment as a means of improving care quality and value, despite mixed real-world implementation outcomes.

OBJECTIVE

This study aimed to explore the factors that influence the integration of a peripheral arterial disease (PAD) identification algorithm to implement timely guideline-based care.

METHODS

A total of 12 semistructured interviews were conducted with individuals from 3 stakeholder groups during the first 4 weeks of integration of an ML-driven CDS. The stakeholder groups included technical, administrative, and clinical members of the team interacting with the ML-driven CDS. The ML-driven CDS identified patients with a high probability of having PAD, and these patients were then reviewed by an interdisciplinary team that developed a recommended action plan and sent recommendations to the patient's primary care provider. Pseudonymized transcripts were coded, and thematic analysis was conducted by a multidisciplinary research team.

RESULTS

Three themes were identified: positive factors translating in silico performance to real-world efficacy, organizational factors and data structure factors affecting clinical impact, and potential challenges to advancing equity. Our study found that the factors that led to successful translation of in silico algorithm performance to real-world impact were largely nontechnical, given adequate efficacy in retrospective validation, including strong clinical leadership, trustworthy workflows, early consideration of end-user needs, and ensuring that the CDS addresses an actionable problem. Negative factors of integration included failure to incorporate the on-the-ground context, the lack of feedback loops, and data silos limiting the ML-driven CDS. The success criteria for each stakeholder group were also characterized to better understand how teams work together to integrate ML-driven CDS and to understand the varying needs across stakeholder groups.

CONCLUSIONS

Longitudinal and multidisciplinary stakeholder engagement in the development and integration of ML-driven CDS underpins its effective translation into real-world care. Although previous studies have focused on the technical elements of ML-driven CDS, our study demonstrates the importance of including administrative and operational leaders as well as an early consideration of clinicians' needs. Seeing how different stakeholder groups have this more holistic perspective also permits more effective detection of context-driven health care inequities, which are uncovered or exacerbated via ML-driven CDS integration through structural and organizational challenges. Many of the solutions to these inequities lie outside the scope of ML and require coordinated systematic solutions for mitigation to help reduce disparities in the care of patients with PAD.

Education and electronic medical records and genomics network, challenges, and lessons learned from a large-scale clinical trial using polygenic risk scores

Polygenic risk scores (PRS) have potential to improve health care by identifying individuals that have elevated risk for common complex conditions. Use of PRS in clinical practice, however, requires careful assessment of the needs and capabilities of patients, providers, and health care systems. The electronic Medical Records and Genomics (eMERGE) network is conducting a collaborative study which will return PRS to 25,000 pediatric and adult participants. All participants will receive a risk report, potentially classifying them as high risk (∼2-10% per condition) for 1 or more of 10 conditions based on PRS. The study population is enriched by participants from racial and ethnic minority populations, underserved populations, and populations who experience poorer medical outcomes. All 10 eMERGE clinical sites conducted focus groups, interviews, and/or surveys to understand educational needs among key stakeholders-participants, providers, and/or study staff. Together, these studies highlighted the need for tools that address the perceived benefit/value of PRS, types of education/support needed, accessibility, and PRS-related knowledge and understanding. Based on findings from these preliminary studies, the network harmonized training initiatives and formal/informal educational resources. This paper summarizes eMERGE's collective approach to assessing educational needs and developing educational approaches for primary stakeholders. It discusses challenges encountered and solutions provided.

Clustering of Health Behaviors in Canadians: A Multiple Behavior Analysis of Data from the Canadian Longitudinal Study on Aging

BACKGROUND

Health behaviors such as physical inactivity, unhealthy eating, smoking tobacco, and alcohol use are each leading risk factors for non-communicable chronic disease. Better understanding which behaviors tend to co-occur (i.e., cluster together) and co-vary (i.e., are correlated) may provide novel opportunities to develop more comprehensive interventions to promote multiple health behavior change. However, whether co-occurrence or co-variation-based approaches are better suited for this task remains relatively unknown.

PURPOSE

To compare the utility of co-occurrence vs. co-variation-based approaches for understanding the interconnectedness between multiple health-impacting behaviors.

METHODS

Using baseline and follow-up data (N = 40,268) from the Canadian Longitudinal Study of Aging, we examined the co-occurrence and co-variation of health behaviors. We used cluster analysis to group individuals based on their behavioral tendencies across multiple behaviors and to examine how these clusters are associated with demographic characteristics and health indicators. We compared outputs from cluster analysis to behavioral correlations and compared regression analyses of clusters and individual behaviors predicting future health outcomes.

RESULTS

Seven clusters were identified, with clusters differentiated by six of the seven health behaviors included in the analysis. Sociodemographic characteristics varied across several clusters. Correlations between behaviors were generally small. In regression analyses individual behaviors accounted for more variance in health outcomes than clusters.

CONCLUSIONS

Co-occurrence-based approaches may be more suitable for identifying sub-groups for intervention targeting while co-variation approaches are more suitable for building an understanding of the relationships between health behaviors.

Longitudinal Dietary Trajectories With Cognitive and Psychosocial Well-Being in Chinese Adults Aged 85 Years and Older in Singapore

Background and Objectives

Studies on longitudinal trajectories of diet and the influence on aging in older adults are limited. We characterized diet quality trajectories over the past 2 decades among adults aged ≥85 years and examined their associations with cognitive and psychosocial outcomes.

Research Design and Methods

We used data from 861 participants in the population-based Singapore Chinese Health Study. Dietary intakes were assessed at baseline (mean age [range]: 65 [60-74] years) and at follow-ups 3 (85 [81-95]) and 4 (88 [85-97]) years. Diet quality was measured by adherence to the Dietary Approaches to Stop Hypertension pattern, and group-based trajectory modeling was used to derive diet quality trajectories. At Follow-up 4, we assessed cognition using the Singapore-modified Mini-Mental State Examination, depressive symptoms using the 15-item Geriatric Depression Scale, social engagement, and self-rated health. Multivariable logistic regression models examined associations of diet quality trajectories with these outcomes.

Results

About 49.7% had a trajectory with consistently low diet quality scores, whereas 50.3% had a trajectory with consistently high diet quality scores. Compared to the "consistently low" trajectory, the "consistently high" trajectory had 29% and 26% lower likelihoods of cognitive impairment and depressive symptoms, respectively (odds ratio, 95% confidence interval: 0.71 [0.51, 0.99] and 0.74 [0.55, 0.99], respectively); as well as 47% higher likelihood of social engagement (1.47 [1.09, 1.98]). No statistically significant association was observed between the trajectories and self-rated health.

Discussion and Implications

Maintaining high diet quality throughout the older adult life course was associated with better cognitive and psychosocial well-being in adults aged ≥85 years.

What drives health mindset and expectations in the United States?

Health mindset is a group of beliefs or assumptions that individuals hold about the causes of health and well-being. Strengthening our understanding of factors that shape mindset and how mindset shapes expectations for who can and should be responsible for health can inform the success and sustainability of solutions to current health crises including the COVID-19 pandemic, ongoing disparities in health outcomes, and gun violence. We first examined associations between personal characteristics and experiences with health mindset. Next, we examined the association between mindset and the belief that government involvement can help address pressing health questions, using obesity as an example of a health outcome that is shaped both by personal choices and factors outside one's control. Going forward, it will be important to consider health mindset in broader transformations of the health system and population approaches to improving health.

Economic, cognitive, and social paths of education to health-related behaviors: evidence from a population-based study in Japan

BACKGROUND

There is substantial evidence on the association between lower education and unhealthy behaviors. However, the mechanism underlying this association remains unclear. This study aimed to examine whether income, health literacy, and social support mediate the association between education and health-related behaviors.

METHODS

A questionnaire survey was conducted in metropolitan areas in Japan from 2010 to 2011 among residents aged 25-50 years. Data from 3663 participants were used in this study. Health literacy was measured using the Communicative and Critical Health Literacy scale. Health-related behaviors were current smoking, poor dietary habits, hazardous drinking, and lack of exercise. Poisson regression analyses with robust variance estimators were conducted to examine the associations between education and these health-related behaviors. Multiple mediation analyses were conducted to estimate the magnitudes of the mediating effects of income, health literacy, and social support on these associations.

RESULTS

Less educated participants had higher risks of all unhealthy behaviors. Income mediated the associations of education with smoking (6.4%) and exercise (20.0%). Health literacy mediated the associations of education with dietary habits (15.4%) and exercise (16.1%). Social support mediated the associations of education with dietary habits (6.4%) and exercise (7.6%). The education-drinking association was mediated by income in the opposite direction (-10.0%). The proportions of the total effects mediated by income, health literacy, and social support were 9.8% for smoking, 24.0% for dietary habits, -3.0% for drinking, and 43.7% for exercise.

CONCLUSIONS

These findings may provide clues for designing effective interventions to reduce educational inequalities in health-related behaviors.

Attitudes among Parents towards Return of Disease-Related Polygenic Risk Scores (PRS) for Their Children

The electronic MEdical Records and GEnomics (eMERGE) consortium will return risk reports pertaining to specific diseases, a key component of which will be polygenic risk scores (PRS), to 25,000 participants, including 5000 children. Understanding comprehension and the perceived value of these PRS-based reports among parents will be critical for effective return of results in children. To address this issue, we conducted semi-structured interviews with 40 African American and Hispanic parents at The Children's Hospital of Philadelphia and Boston Children's Hospital. Each participant received a hypothetical risk report identifying their child as high risk for either type 2 diabetes or asthma. Participants were assessed on their comprehension of absolute versus relative risk framing, likelihood of following risk-reduction recommendations, perceived value of the information, psychosocial impact, education/support needed, and suggestions to improve the PRS-based report to make it more accessible. Results demonstrated high perceived value in receiving PRS-based reports but also draws attention to important shortfalls in comprehension due to factors including the health of the child, family history, and how the risk was framed. This study provides an insight into implementing the return of genomic risk scores in a pediatric setting.

It is time to Go All In: a call to action

Even though there have been numerous advances in medicine and technology in the past few decades, the length and quality of life vary significantly based on a person’s race, ethnicity, gender identity, sexual orientation, disability status, geographic residence, and/or socioeconomic status. In fact, membership in one or more marginalized sociodemographic groups is particularly associated with worse healthcare access and health outcomes. Behavioral medicine is uniquely equipped to advance health equity through inclusive and innovative research and practice and exerted influence on policies and practices that contribute to health disparities.

Priorities for improvement across cancer and non-cancer related preventive services among rural and non-rural clinicians

Introduction

It is not realistic for most clinicians to perform the multitude of recommended preventive primary care services. This is especially true in low resource and rural settings, creating challenges to delivering high-quality care. This study collected stakeholder input from clinicians on which services they most need to improve.

Methods

The authors conducted a survey of primary care physicians 9–12/2021, with an emphasis on rural practices, to assess areas in which clinicians felt the greatest needs for improvement. The survey focused on primary prevention (behavior change counseling) and cancer screening, and contrasted needs for improvement for these services vs. other types of screening, and between clinicians in rural vs. non-rural practices.

Results

There were 326 respondents from 4 different practice-based research networks, a wide range of practice types, 49 states and included 177 clinicians in rural settings. Respondents rated the need to improve delivery of primary prevention counseling services highest, with needs for nutrition and dietary assessment and counseling rated highest followed by physical activity and with almost no differences between rural and nonrural. Needs for improvement in cancer screenings were rated higher than non-cancer screenings, except for blood pressure screening.

Conclusions

Both rural and nonrural primary care clinicians feel a need for improvement, especially with primary prevention activities. Although future research is needed to replicate these findings with different populations and other types of preventive service activities, greater priority should be given to development of practical, stakeholder informed assistance and resources for primary care to conduct primary prevention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01845-1.

Nonadherence to health promotion depending on chronic obstructive pulmonary disease severity

BACKGROUND

Nonadherence to recommended health behaviors reportedly correlates with the prevalence and health outcomes of COPD, but the factors contributing to multiple health promotions are not well understood.

OBJECTIVE

To examine the factors associated with nonadherence to health behaviors, specifically focusing on COPD severity.

METHODS

We conducted a secondary data analysis with data from the 2016-2019 Korea National Health and Nutrition Examination Survey. The analyzed data were from 1,627 individuals aged over 40 years who had a FEV1/FVC ratio < 70% measured via spirometer. In this study, nonadherence to health behaviors is the sum of seven health-promoting behaviors in terms of smoking cessation, alcohol abstinence, regular exercise, weight control, recommended sleep time, influenza vaccination, and medical check-up.

RESULTS

COPD patients' nonadherence to health behaviors was significantly associated with comorbidity (p=0.017), stress (p=0.002), and COPD severity (moderate, severe; p=0.010, p=0.039, respectively). In addition, the moderate and severe COPD groups showed a higher nonadherence rate than the mild COPD group. Specifically, nonadherence to weight control was the most significantly different behavior according to COPD severity levels, based on the GOLD classification of airflow limitation.

CONCLUSION

Our study findings support that those with higher levels of stress, comorbidities, and severe disease conditions are less likely to adhere to health behaviors. Thus, healthcare providers and policymakers should provide tailored approaches according to COPD severity to educate and support appropriate health behaviors for individuals with COPD.

Thinking Health-related Behaviors in a Climate Change Context: A Narrative Review

BACKGROUND

Human activities have changed the environment so profoundly over the past two centuries that human-induced climate change is now posing serious health-related threats to current and future generations. Rapid action from all scientific fields, including behavioral medicine, is needed to contribute to both mitigation of, and adaption to, climate change.

PURPOSE

This article aims to identify potential bi-directional associations between climate change impacts and health-related behaviors, as well as a set of key actions for the behavioral medicine community.

METHODS

We synthesized the existing literature about (i) the impacts of rising temperatures, extreme weather events, air pollution, and rising sea level on individual behaviors (e.g., eating behaviors, physical activity, sleep, substance use, and preventive care) as well as the structural factors related to these behaviors (e.g., the food system); and (ii) the concurrent positive and negative roles that health-related behaviors can play in mitigation and adaptation to climate change.

RESULTS

Based on this literature review, we propose a first conceptual model of climate change and health-related behavior feedback loops. Key actions are proposed, with particular consideration for health equity implications of future behavioral interventions. Actions to bridge the fields of behavioral medicine and climate sciences are also discussed.

CONCLUSIONS

We contend that climate change is among the most urgent issues facing all scientists and should become a central priority for the behavioral medicine community.

Mental and Physical Health Concerns in the Context of COVID-19: Opportunities and Applications for Behavioral Medicine

Numerous physical and mental health concerns have been documented in the context of COVID-19, and it is likely that patients, survivors, frontline health care workers, and other affected individuals will present to psychiatry for treatment. Behavioral medicine, an interdisciplinary field that is defined by a behavioral and biomedical conceptualization of clinical care, offers an opportunity for collaboration with psychiatry and other health care providers to meet the myriad needs resulting from the pandemic. This review summarizes a conceptual framework of behavioral medicine and clinical health psychology, COVID-19-related quality of life concerns that may be applicable to behavioral medicine referrals, clinical assessment directions, and intervention opportunities. The review combines both findings specific to COVID-19 and general behavioral medicine principles with an overall goal of providing a basic introduction to behavioral medicine practice, applications, and opportunities for management of medical and psychological symptoms.

Peer Group Support Intervention to Reduce Cardiovascular Disease Risk for African American Men According to Life's Simple 7 in Faith-Based Communities

BACKGROUND AND PURPOSE

Adverse cardiovascular health disparities persist for African American men. Although changing health behaviors is perhaps one of the most effective methods to prevent cardiovascular disease (CVD)-related deaths, previous behavior change programs targeting single or multiple CVD risk factors in target groups have had mixed success. The purpose of this pilot study was to determine whether a multi-faceted peer group intervention model based on American Heart Association's Life's Simple 7 was feasible, safe, acceptable, and efficacious in producing meaningful risk reduction for African American men.

METHODS

A convenience sample of 24 African American men with at least one CVD risk factor participated quasi-experimental study having peer intervention vs. nonequivalent comparison groups, with pretest-posttests at two church sites in Minneapolis, MN (MPLS) and Washington, D.C. (DC). Feasibility, safety, acceptability, and potential efficacy were assessed by examining completion of peer group sessions, adverse events, attendance, attrition, within and between-group changes in measures using nonparametric statistics.

RESULTS

All twenty-four men completed the study with no study-related adverse symptoms and medical events. The peer groups had moderate to high attendance, and the peer program evaluation was highly positive among participants. Between baseline and 6-months, there were significant differences between the intervention and the comparison group in cholesterol levels and weights (p = .041, p = .034, respectively) at one site (DC). There were no significant between-group changes at the other site (MPLS).

IMPLICATION FOR PRACTICE

The multi-faceted peer support intervention was feasible, acceptable, and shown to have potential efficacy to reduce CVD risk for highly motivated African American men. Future studies with a larger sample size are needed to test the effectiveness of this intervention model to reduce CVD risk among African American men.

Incorporating Mental Health Into Lifestyle Medicine

The evidence-based interconnection between mental health with lifestyle medicine practice is discussed. The extent to which physical health, and mental and behavioral health overlap are significant, and their interaction is seen in many ways. These bidirectional influences form a continuous thread through all lifestyle medicine pillars. The intersection of mental health and lifestyle should be considered and applied to provide optimal evidence-based lifestyle medicine for all patient populations who will benefit from the specific attention to diet, physical activity, relationships, stress, sleep, and substance use. Lifestyle medicine can be utilized to directly address and treat a range of mental health symptoms and disorders, and physical illnesses. In addition, behavior change skills and addressing the psychological factors contributing to barriers are crucial to helping patients reach their lifestyle medicine goals. Approaches to practice that attend to, and address, mental and behavioral health are relevant to and necessary for all types of providers who work within the lifestyle medicine framework.

Inequality in the Utilization of Breast Cancer Screening between Women with and without Disabilities in Taiwan: A Propensity-Score-Matched Nationwide Cohort Study

Because of the difficulties in accessing medical care, the likelihood of receiving breast cancer screening may be low for women with disabilities. We aimed to investigate differences in the utilization of breast cancer screening among women with and without disabilities. Participants included women with and without disabilities from 2004 to 2010, and it was observed whether the participants had received a breast cancer screening during 2011 and 2012. Propensity-score matching was employed to match disabled women with non-disabled women (1:1). Data sources included the National Health Insurance Research Database, the Cancer Screening Database, and the Disability Registration File. Conditional logistic regression was performed to examine the odds ratios (ORs) that both groups would undergo breast cancer screening. The proportion of women with disabilities who received breast cancer screening was 18.33%, which was significantly lower than that of women without disabilities (25.52%) (p < 0.001). Women with dementia had the lowest probability of receiving a mammography examination (OR = 0.34; 95% CI: 0.28−0.43), followed by those with multiple disabilities (OR = 0.43; 95% CI: 0.40−0.47) and intellectual disabilities (OR = 0.45; 95% CI: 0.41−0.50). In conclusion, compared to women without disabilities, those with disabilities were less likely to undergo breast cancer screening.

Clinical Outcomes Among Working Adults Using the Health Integrator Smartphone App: Analyses of Prespecified Secondary Outcomes in a Randomized Controlled Trial

Background

There is a need to find new methods that can enhance the individuals’ engagement in self-care and increase compliance to a healthy lifestyle for the prevention of noncommunicable diseases and improved quality of life. Mobile health (mHealth) apps could provide large-scale, cost-efficient digital solutions to implement lifestyle change, which as a corollary may enhance quality of life.

Objective

Here we evaluate if the use of a smartphone-based self-management system, the Health Integrator app, with or without telephone counseling by a health coach, had an effect on clinical variables (secondary outcomes) of importance for noncommunicable diseases.

Methods

The study was a 3-armed parallel randomized controlled trial. Participants were randomized to a control group or to 1 of 2 intervention groups using the Health Integrator app with or without additional telephone counseling for 3 months. Clinical variables were assessed before the start of the intervention (baseline) and after 3 months. Due to the nature of the intervention, targeting lifestyle changes, participants were not blinded to their allocation. Robust linear regression with complete case analysis was performed to study the intervention effect among the intervention groups, both in the entire sample and stratifying by type of work (office worker vs bus driver) and sex.

Results

Complete data at baseline and follow-up were obtained from 205 and 191 participants, respectively. The mean age of participants was 48.3 (SD 10) years; 61.5% (126/205) were men and 52.2% (107/205) were bus drivers. Improvements were observed at follow-up among participants in the intervention arms. There was a small statistically significant effect on waist circumference (β=–0.97, 95% CI –1.84 to –0.10) in the group receiving the app and additional coach support compared to the control group, but no other statistically significant differences were seen. However, participants receiving only the app had statistically significantly lower BMI (β=–0.35, 95% CI –0.61 to –0.09), body weight (β=–1.08, 95% CI –1.92 to –0.26), waist circumference (β=–1.35, 95% CI –2.24 to –0.45), and body fat percentage (β=–0.83, 95% CI –1.65 to –0.02) at follow-up compared to the controls. There was a statistically significant difference in systolic blood pressure between the two intervention groups at follow-up (β=–3.74, 95% CI –7.32 to –0.16); no other statistically significant differences in outcome variables were seen.

Conclusions

Participants randomized to use the Health Integrator smartphone app showed small but statistically significant differences in body weight, BMI, waist circumference, and body fat percentage compared to controls after a 3-month intervention. The effect of additional coaching together with use of the app is unclear.

Trial Registration

ClinicalTrials.gov NCT03579342; https://clinicaltrials.gov/ct2/show/NCT03579342

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-019-6595-6

Correlations between Physical Activity Participation and the Environment in Children and Adolescents: A Systematic Review and Meta-Analysis Using Ecological Frameworks

Physical activity (PA) and sports are efficient ways to promote the young generation’s physical and mental health and development. This study expected to demonstrate the complexity of correlates associated with children’s and adolescents’ non-organized PA participation. Following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA), a systematic review and meta-analysis were applied. Seven electronic databases were systematically searched to identify eligible articles based on a series of inclusion and exclusion criteria. The internal validity of the systematic reviews thus identified was evaluated using a validated quality instrument. Calculations were produced in SPSS 27.0 and Comprehensive Meta-Analysis 3.3. Thirty-nine eligible studies (N = 324,953) with moderate to high quality were included. No potential publication bias was detected using statistical analyses. The meta-analysis revealed that the overall ecological factors correlated positively with children and adolescents’ PA; the meta-analytic average of the correlations was (′r = 0.32, p < 0.001). Results from subgroup analysis indicated that theory-based influence factors achieved moderate effect with boys (′r = 0.37, p < 0.001) and girls (′r = 0.32, p < 0.001) in PA participation. Interestingly, higher correlations were found between ecological factors and twins’ PA participation (′r = 0.61, p = 0.001). Further, individual (′r = 0.32, p < 0.001), macro-, and chronosystems factors (′r = 0.50, p < 0.001) appeared slightly more influential than microsystems factors (′r = 0.28, p < 0.001) on children and adolescents’ PA participation. Although findings from the included studies covered were to some extent heterogeneous, it is possible to identify consistent correlates of PA in children and adolescents. The results supported that PA is a complex and multi-dimensional behavior, which is determined by numerous biological, psychological, sociocultural, and environmental factors. Future studies that focus on the integration effect of macrosystem and chronosystem environmental factors, and apply longitudinal designs and objective measurements are encouraged to further unfold the complexity of the ecological system and its implications in promoting children and adolescents’ PA participation.

Improving the Sexual Health of Young People (under 25) in High-Risk Populations: A Systematic Review of Behavioural and Psychosocial Interventions

Background: Ensuring young people experience good sexual health is a key public health concern, yet some vulnerable groups of young people remain at higher risk of poor sexual health. These individuals require additional support to achieve good sexual health but the best way to provide this remains needs to be better understood. Methods: We searched for randomised controlled trials of behavioural and psychosocial interventions aimed at promoting sexual health in high-risk young populations. Outcomes of interest were indicators of sexual health (e.g., condom use, attitudes to contraception, knowledge of risk). Participants were under 25 years old and in one of the following high-risk groups: alcohol and other drug use; ethnic minority; homeless; justice-involved; LGBTQI+; mental ill-health; or out-of-home care. Results: Twenty-eight papers from 26 trials met our inclusion criteria, with all but one conducted in North America. Condom use was the most frequently reported outcome measure along with knowledge and attitudes towards sexual health but considerable differences in measures used made comparisons across studies difficult. Change in knowledge and attitudes did not consistently result in long-term change in behaviours. Conclusions: There remains a dearth of research undertaken outside of North America across all high-risk groups of young people. Future interventions should address sexual health more broadly than just the absence of negative biological outcomes, with LGBTQI+, homeless and mental ill-health populations targeted for such work. An international consensus on outcome measures would support the research field going forward, making future meta-analyses possible.

Sociodemographic disparity in health-related behaviours and dietary habits among public workers in China: a cross-sectional study

OBJECTIVE

We aimed to estimate the distribution of health-related behaviours and dietary habits by sociodemographics among public workers in China.

DESIGN

Cross-sectional study.

SETTING

A representative sample was obtained from 10 government-run institutions in Hunan province of China.

PARTICIPANTS

A total of 5029 public workers were included in this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence on their sociodemographic characteristics, health-related behaviours and dietary habits. Socioeconomic status (SES) scores were calculated by multiplying ordinal numerical values assigned to consecutive categories of education level and annual household income. Multivariate logistic regression analysis and categorical principal component analysis were used to estimate differences in health-related behaviours and dietary habits by sociodemographics.

RESULTS

The distribution of health-related behaviours and dietary habits was varied by sociodemographic groups. Middle-aged groups (41-60 years) were more likely to smoke (for men, 34.5%), use alcohol (for men, 22.5%), and have short sleep duration (for men, 36.3%; for women, 39.6%). Young participants (≤30 years) were more likely to have multiple unhealthy behaviours and dietary habits. Those in low-SES have a significant higher rate of smoking (OR_adj=1.46, 95% CI: 1.15 to 1.85) and leisure-time physical inactivity (OR_adj=1.18, 95% CI: 1.02 to 1.37), but a lower rate of late sleeping (OR_adj=0.69, 95% CI: 0.57 to 0.83) than those in high-SES. Notably, older men (≥51 years) with low-SES preferred the 'smoked and pickled foods and dessert' and 'fish and nut' pattern. In high-SES groups, 41-50 year old people preferred the 'traditional foods' and 'cereals and dairy product' pattern. No difference in dietary patterns by sociodemographics was found among women (p<0.05).

CONCLUSIONS

Our findings of the disparity distribution of health-related behaviours and dietary habits by specific gender, age and SES among Chinese public workers have important policy implications for developing targeted health interventions to facilitate health-related behaviours and dietary habits in this population.

Clustering of Unhealthy Behaviors: Protocol for a Multiple Behavior Analysis of Data From the Canadian Longitudinal Study on Aging

BACKGROUND

Health behaviors such as physical inactivity, unhealthy eating, smoking tobacco, and alcohol use are leading risk factors for noncommunicable chronic diseases and play a central role in limiting health and life satisfaction. To date, however, health behaviors tend to be considered separately from one another, resulting in guidelines and interventions for healthy aging siloed by specific behaviors and often focused only on a given health behavior without considering the co-occurrence of family, social, work, and other behaviors of everyday life.

OBJECTIVE

The aim of this study is to understand how behaviors cluster and how such clusters are associated with physical and mental health, life satisfaction, and health care utilization may provide opportunities to leverage this co-occurrence to develop and evaluate interventions to promote multiple health behavior changes.

METHODS

Using cross-sectional baseline data from the Canadian Longitudinal Study on Aging, we will perform a predefined set of exploratory and hypothesis-generating analyses to examine the co-occurrence of health and everyday life behaviors. We will use agglomerative hierarchical cluster analysis to cluster individuals based on their behavioral tendencies. Multinomial logistic regression will then be used to model the relationships between clusters and demographic indicators, health care utilization, and general health and life satisfaction, and assess whether sex and age moderate these relationships. In addition, we will conduct network community detection analysis using the clique percolation algorithm to detect overlapping communities of behaviors based on the strength of relationships between variables.

RESULTS

Baseline data for the Canadian Longitudinal Study on Aging were collected from 51,338 participants aged between 45 and 85 years. Data were collected between 2010 and 2015. Secondary data analysis for this project was approved by the Ottawa Health Science Network Research Ethics Board (protocol ID #20190506-01H).

CONCLUSIONS

This study will help to inform the development of interventions tailored to subpopulations of adults (eg, physically inactive smokers) defined by the multiple behaviors that describe their everyday life experiences.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24887.

Physical Activity Participation and the Environment in Children and Adolescents: A Systematic Review and Meta-Analysis Protocol

Physical activity (PA) and sports are efficient ways to promote the younger generation’s health and wellbeing. However, evidence is limited due to heterogeneous samples and measurements. This study aims to identify promoting and inhibiting correlates associated with children’s and adolescents’ non-organized PA participation and further demonstrate the complexity of PA and ecological factors. A systematic review and meta-analysis will be applied by following the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). Seven bibliographic databases (PubMed, SPORTDiscus, PsycInfo, MEDLINE Complete, ERIC, Dimensions, and Academic Search Complete) will be systematically searched to identify eligible articles based on a series of inclusion and exclusion criteria. Inclusion criteria are that the study: (a) is not classified as a systematic review with or without meta-analysis; (b) is published in last 20 years; (c) includes children and adolescents; (d) quantitively measures PA; (e) includes review of ecological factors. The internal validity will be evaluated using a validated quality instrument. Calculations will be produced in SPSS 27.0 and Comprehensive Meta-Analysis 3.3. This study will provide evidence and address the questions regarding the factors that significantly impact children’s PA participation and limitations regarding the design, sampling, and measurement in currently selected studies. PROSPERO registration number: CRD42021244918.

Sustained Benefit of Alternate Behavioral Interventions to Improve Hypertension Control: A Randomized Clinical Trial

Supplemental Digital Content is available in the text.

Little is known about the long-term effects of behavioral interventions to improve blood pressure (BP) control. We evaluated whether a telephone-delivered, behavioral stage-matched intervention (SMI), or a nontailored health education intervention (HEI) delivered for 6 months improves BP control (or lowers systolic BP) over 12 months, as well as its sustainability 6 months after intervention implementation ended, compared with usual care in participants with repeated uncontrolled BP at baseline. A 3-arm, randomized controlled trial was designed to evaluate the effectiveness of 2 interventions, each compared with a usual-care control group. Participants were 533 adults with persistent uncontrolled BP who were treated at 2 Veterans Affairs Medical Centers. The intervention was implemented for 6 months, followed by 6 months of observation. Compared with usual care, the odds of having BP under control over 12 months in SMI were 84% higher (odds ratio, 1.84 [95% CI, 1.28–2.67]; P=0.001), and 48% higher in HEI (odds ratio, 1.48 [95% CI, 1.02–2.14]; P=0.04).Over the 12 months, compared with usual care, systolic blood pressure was 2.80 mm Hg lower in SMI ([95% CI, 0.27 to 5.33]; P=0.03) while it was 2.58 mm Hg lower in HEI ([95% CI, −0.40 to 5.55]; P=0.09). From 6 to 12 months, SMI sustained improved BP control and lower systolic blood pressure, while HEI, which did not have significantly better BP control or lower systolic blood pressure at 6 months, appeared to improve BP control and lower systolic blood pressure. SMI and HEI are promising interventions that can be implemented in clinical practice to improve BP management.

Leveraging applied behavior analysis research and practice in the service of public health

Human behavior plays a central role in all domains of public health. Applied behavior analysis (ABA) research and practice can contribute to public health solutions that directly address human behavior. In this paper, we describe the field of public health, identify points of interaction between public health and ABA, summarize what ABA research has already contributed, and provide several recommendations for how ABA research and practice could continue to promote public health outcomes. A clearer focus on behavior and widespread adoption of research designs and interventions informed by the ABA literature could lead to better public health outcomes. Reciprocally, better integration of public health goals and strategies into ABA research, harnessing of technology, and more collaboration would help diversify and disseminate our applied science and could yield more effective and scalable interventions to prevent and treat public health problems.

Behavioral Medicine for Sedentary Behavior, Daily Physical Activity, and Exercise to Prevent Cardiovascular Disease: A Review

PURPOSE OF REVIEW

Behavioral medicine is a multidisciplinary field that has a key role in reducing risk factors for cardiovascular disease (CVD). The purpose of this review is to describe the role of behavioral medicine for CVD prevention, using physical activity behaviors (e.g., sedentary behavior, daily physical activity, or exercise) as an exemplar. Application of behavioral medicine to improve dietary behaviors is also briefly discussed.

RECENT FINDINGS

Behavioral medicine interventions that address physical activity behaviors are associated with improved cardiovascular risk factors. Interventions framed in behavior change theory that integrate behavior change techniques to reduce sedentary behavior and promote daily physical activity and exercise have similarly been applied to improve certain dietary behaviors and show promise for reducing CVD risk factors. Behavioral medicine has an important role in improving various physical activity behaviors for all populations, which is essential for preventing or managing CVD. Further investigation into behavioral medicine interventions that address personal, environmental, and social factors that influence participation in physical activity behaviors, as well as the adoption of a more optimal dietary pattern, is warranted.

What Is Slowing Us Down? Six Challenges to Accelerating Advances in Health Behavior Change

BACKGROUND

Accelerating advances in health behavior change requires releasing the brake, as well as applying the throttle. This paper discusses six challenges or "brakes" that have slowed progress.

PURPOSE/METHODS/RESULTS

We engage with six issues that limit investigators' ability to delineate and test the strategy-target and target-behavior relations that underlie effective interventions according to the experimental medicine approach. We discuss the need for guidance on how to identify the relevant mechanism of action (target) in an intervention and whether a periodic table of health behavior constructs might aid investigators. Experimental and correlational analyses (prospective surveys and behavior change techniques) have been used to test the validity of targets, and we present evidence that there is little agreement among the findings from different research designs. Whereas target engagement is typically analyzed in terms of increasing scores on constructs that impel behavior change, we discuss the role of impeding targets and the benefits of adopting a broader construal of potential targets and approaches to engagement. There is presently a paucity of competitive tests regarding which strategies best engage targets and we discuss empirical criteria and conceptual developments that could enhance the evidence base. Finally, we highlight the need to take "context" or conditional intervention effects more seriously by leveraging the interplay between questions about why interventions work and questions about when and for whom they work.

CONCLUSION

Candid appraisal of the challenges facing research on health behavior change can generate new opportunities for theoretical development and offer direction and cumulative impetus for empirical work.

Locomotion in virtual environments predicts cardiovascular responsiveness to subsequent stressful challenges

Individuals differ in their physiological responsiveness to stressful challenges, and stress potentiates the development of many diseases. Heart rate variability (HRV), a measure of cardiac vagal break, is emerging as a strong index of physiological stress vulnerability. Thus, it is important to develop tools that identify predictive markers of individual differences in HRV responsiveness without exposing subjects to high stress. Here, using machine learning approaches, we show the strong predictive power of high-dimensional locomotor responses during novelty exploration to predict HRV responsiveness during stress exposure. Locomotor responses are collected in two ecologically valid virtual reality scenarios inspired by the animal literature and stress is elicited and measured in a third threatening virtual scenario. Our model's predictions generalize to other stressful challenges and outperforms other stress prediction instruments, such as anxiety questionnaires. Our study paves the way for the development of behavioral digital phenotyping tools for early detection of stress-vulnerable individuals.

The RESPECT study: a feasibility randomised controlled trial of a sexual health promotion intervention for people with serious mental illness in community mental health services in the UK

Background

People with serious mental illness (SMI) have sexual health needs but there is little evidence to inform effective interventions to address them. In fact, there are few studies that have addressed this topic for people with SMI outside USA and Brazil. Therefore, the aim of the study was to establish the acceptability and feasibility of a trial of a sexual health promotion intervention for people with SMI in the UK.

Method

The RESPECT study was a two-armed randomised controlled, open feasibility trial (RCT) comparing Sexual health promotion intervention (3 individual sessions of 1 h) (I) or treatment as usual (TAU) for adults aged 18 or over, with SMI, within community mental health services in four UK cities. The main outcome of interest was the percentage who consented to participate, and retained in each arm of the trial, retention for the intervention, and completeness of data collection. A nested qualitative study obtained the views of participants regarding the acceptability of the study using individual telephone interviews conducted by lived experience researchers.

Results

Of a target sample of 100, a total of 72 people were enrolled in the trial over 12 months. Recruitment in the initial months was low and so an extension was granted. However this extension meant that the later recruited participants would only be followed up to the 3 month point. There was good retention in the intervention and the study as a whole; 77.8% of those allocated to intervention (n = 28) received it. At three months, 81.9% (30 I; 29 TAU) and at 6 months, 76.3% (13 I and 16 TAU) completed the follow-up data collection. No adverse events were reported. There was good completeness of the data. The sexual health outcomes for the intervention group changed in favour of the intervention. Based on analysis of the qualitative interviews, the methods of recruitment, the quality of the participant information, the data collection, and the intervention were deemed to be acceptable to the participants (n = 22).

Conclusions

The target of 100 participants was not achieved within the study’s timescale. However, effective strategies were identified that improved recruitment in the final few months. Retention rates and completeness of data in both groups indicate that it is acceptable and feasible to undertake a study promoting sexual health for people with SMI. A fully powered RCT is required to establish effectiveness of the intervention in adoption of safer sex.

Study registration

ISRCTN RegistryISRCTN15747739 prospectively registered 5th July 2016.

Sexual health promotion in people with severe mental illness: the RESPECT feasibility RCT

BACKGROUND

People with serious mental illness have sexual health needs, but there is limited evidence regarding effective interventions to promote their sexual health.

OBJECTIVES

To develop a sexual health promotion intervention for people with serious mental illness, and to conduct a feasibility trial in order to establish the acceptability and parameters for a fully powered trial.

DESIGN

A two-armed randomised controlled, open feasibility study comparing usual care alone with usual care plus the adjunctive intervention.

SETTING

Five community mental health providers in Leeds, Barnsley, Brighton and London.

PARTICIPANTS

Adults aged ≥ 18 years with serious mental illness and receiving care from community mental health teams.

INTERVENTIONS

A remote, web-based computer randomisation system allocated participants to usual care plus the RESPECT (Randomised Evaluation of Sexual health Promotion Effectiveness informing Care and Treatment) intervention (three sessions of 1 hour) (intervention arm) or usual care only (control arm). The intervention was an interactive manualised package of exercises, quizzes and discussion topics focusing on knowledge, motivation and behavioural intentions to adopt safer sexual behaviours.

MAIN OUTCOME MEASURES

Feasibility parameters including establishing the percentage of people who were eligible, consented and were retained in each arm of the trial, retention for the intervention, as well as the completeness of the data collection. Data were collected on knowledge, motivation to adopt safer sexual behaviour, sexual behaviour, sexual stigma, sexual health service use and quality of life. Data were collected at baseline and then at 3 months and 6 months post randomisation.

RESULTS

Of a target of 100 participants, 72 people participated in the trial over 12 months. Of the 36 participants randomised to the intervention arm, 27 received some of the intervention (75.0%). At 3 months, 59 of the 72 participants completed follow-up questionnaires (81.9%) (30 participants from the intervention arm and 29 participants from the control arm). Only the first 38 participants were followed up at 6 months. However, data were collected on 29 out of 38 participants (76.3% retention): 13 in the intervention arm and 16 in the control arm. No adverse events were reported. Participant feedback confirmed that both the design and the intervention were acceptable. The economic analysis indicated high completion rates and completeness of data among participants who continued the trial.

CONCLUSIONS

Despite the limitations, the findings suggest that it is both acceptable and feasible to undertake a sexual health promotion study for people with serious mental illness.

FUTURE WORK

A fully powered randomised controlled trial would be required to establish the clinical effectiveness of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15747739.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 65. See the NIHR Journals Library website for further project information.

Sexual health promotion in people with severe mental illness: the RESPECT feasibility RCT

BACKGROUND

People with serious mental illness have sexual health needs, but there is limited evidence regarding effective interventions to promote their sexual health.

OBJECTIVES

To develop a sexual health promotion intervention for people with serious mental illness, and to conduct a feasibility trial in order to establish the acceptability and parameters for a fully powered trial.

DESIGN

A two-armed randomised controlled, open feasibility study comparing usual care alone with usual care plus the adjunctive intervention.

SETTING

Five community mental health providers in Leeds, Barnsley, Brighton and London.

PARTICIPANTS

Adults aged ≥ 18 years with serious mental illness and receiving care from community mental health teams.

INTERVENTIONS

A remote, web-based computer randomisation system allocated participants to usual care plus the RESPECT (Randomised Evaluation of Sexual health Promotion Effectiveness informing Care and Treatment) intervention (three sessions of 1 hour) (intervention arm) or usual care only (control arm). The intervention was an interactive manualised package of exercises, quizzes and discussion topics focusing on knowledge, motivation and behavioural intentions to adopt safer sexual behaviours.

MAIN OUTCOME MEASURES

Feasibility parameters including establishing the percentage of people who were eligible, consented and were retained in each arm of the trial, retention for the intervention, as well as the completeness of the data collection. Data were collected on knowledge, motivation to adopt safer sexual behaviour, sexual behaviour, sexual stigma, sexual health service use and quality of life. Data were collected at baseline and then at 3 months and 6 months post randomisation.

RESULTS

Of a target of 100 participants, 72 people participated in the trial over 12 months. Of the 36 participants randomised to the intervention arm, 27 received some of the intervention (75.0%). At 3 months, 59 of the 72 participants completed follow-up questionnaires (81.9%) (30 participants from the intervention arm and 29 participants from the control arm). Only the first 38 participants were followed up at 6 months. However, data were collected on 29 out of 38 participants (76.3% retention): 13 in the intervention arm and 16 in the control arm. No adverse events were reported. Participant feedback confirmed that both the design and the intervention were acceptable. The economic analysis indicated high completion rates and completeness of data among participants who continued the trial.

CONCLUSIONS

Despite the limitations, the findings suggest that it is both acceptable and feasible to undertake a sexual health promotion study for people with serious mental illness.

FUTURE WORK

A fully powered randomised controlled trial would be required to establish the clinical effectiveness of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15747739.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 65. See the NIHR Journals Library website for further project information.

A Psychometric Approach to Theory-Based Behavior Change Intervention Development: Example From the Colorado Meaning-Activity Project

Background

There has been a notable disconnect between theories of behavior change and behavior change interventions. Because few interventions are both explicitly and adequately theory-based, investigators cannot assess the impact of theory on intervention effectiveness. Theory-based interventions, designed to deliberately engage the theory's proposed mechanisms of change, are needed to adequately test theories. Thus, systematic approaches to theory-based intervention development are needed.

Purpose

This article will introduce and discuss the psychometric method of developing theory-based interventions.

Methods

The psychometric approach to intervention development utilizes basic psychometric principles at each step of the intervention development process in order to build a theoretically driven intervention to, subsequently, be tested in process (mechanism) and outcome studies. Five stages of intervention development are presented as follows: (i) Choice of theory; (ii) Identification and characterization of key concepts and expected relations; (iii) Intervention construction; (iv) Initial testing and revision; and (v) Empirical testing of the intervention.

Results

Examples of this approach from the Colorado Meaning-Activity Project (COMAP) are presented. Based on self-determination theory integrated with meaning or purpose, and utilizing a motivational interviewing approach, the COMAP intervention is individually based with an initial interview followed by smart phone-delivered interventions for increasing daily activity.

Conclusions

The psychometric approach to intervention development is one method to ensure careful consideration of theory in all steps of intervention development. This structured approach supports developing a research culture that endorses deliberate and systematic operationalization of theory into behavior change intervention from the outset of intervention development.

The effectiveness of app-based mobile interventions on nutrition behaviours and nutrition-related health outcomes: A systematic review and meta-analysis

A systematic review and meta-analysis were conducted to assess the effectiveness of app-based mobile interventions for improving nutrition behaviours and nutrition-related health outcomes, including obesity indices (eg, body mass index [BMI]) and clinical parameters (eg, blood lipids). Seven databases were searched for studies published between 2006 and 2017. Forty-one of 10 132 identified records were included, comprising 6348 participants and 373 outcomes with sample sizes ranging from 10 to 833, including 27 randomized controlled trials (RCTs). A beneficial effect of app-based mobile interventions was identified for improving nutrition behaviours (g = 0.19; CI, 0.06-0.32, P = .004) and nutrition-related health outcomes (g = 0.23; CI, 0.11-0.36, P < .001), including positive effects on obesity indices (g = 0.30; CI, 0.15-0.45, P < .001), blood pressure (g = 0.21; CI, 0.01-0.42, P = .043), and blood lipids (g = 0.15; CI, 0.03-0.28, P = .018). Most interventions were composed of four behaviour change technique (BCT) clusters, namely, "goals/planning," "feedback/monitoring," "shaping knowledge," and "social support." Moderating effects including study design, type of app (commercial/research app), sample characteristics (clinical/non-clinical sample), and intervention characteristics were not statistically significant. The inclusion of additional treatment components besides the app or the number or type of BCTs implemented did not moderate the observed effectiveness, which underscores the potential of app-based mobile interventions for implementing effective and feasible interventions operating at scale for fighting the obesity epidemic in a broad spectrum of the population.

Emotion, Social Relationships, and Physical Health: Concepts, Methods, and Evidence for an Integrative Perspective

Emotional characteristics and processes are robust predictors of the development and course of major medical illnesses and premature mortality, as are a variety of indicators of the presence and quality of personal relationships. Despite clear evidence of close interconnection between these two domains of risk and protection, affective characteristics and relationships have largely been studied separately as influences on health. After a recent conference on integrative perspectives on emotions, relationships and health co-sponsored by the American Psychosomatic Society and the Society for Affective Science, the present review builds on prior calls for integration, related theory, and current research to outline what is known about the interconnection of these domains as it specifically relates to their overlapping influences on health. Areas of interest include the following: their interconnected roles over the course of development, which may inform current efforts to understand the influence of early life events on adult health; the parallel positive and negative factors in both domains that could have distinct influences on health; the role of emotion regulation in relationship contexts; and measurement, design, and analysis approaches to capture the dyadic and dynamic aspects of these interconnected influences on health. We conclude with a discussion of an emerging research agenda that includes the following: common biological foundations of affective and relationship processes, the cultural embeddedness of affective and relationship processes, the potential contribution of affective-relational processes to health disparities, and implications for intervention research.

Exploring Psychiatric Inpatients' Beliefs About the Role of Post-discharge Follow-up Care in Suicide Prevention

Introduction:

Patients are at increased risk for death by suicide following a psychiatric hospitalization. There has been limited study of the association between patient engagement in follow-up care after psychiatric hospitalization and suicide risk. Understanding why psychiatric inpatients choose to engage in post-discharge care is important in developing effective suicide prevention strategies.

Materials and Methods:

The theory of planned behavior (TPB) has been widely used to understand many health behaviors including healthcare utilization. Using the TPB, we developed an interview guide that assessed psychiatric inpatients’ attitudes and beliefs about the role of post-discharge care in addressing suicide risk. We also inquired about perception of future risk for suicide after discharge. We conducted semi-structured interviews prior to discharge and administered the Columbia-Suicide Severity Rating Scale (C-SSRS). We assessed healthcare utilization at 1 and 3 mo after discharge. We coded and grouped the transcribed data according to the three domains of the TPB model: attitudes, subjective norms, and perceived behavioral control.

Results:

Sixteen individuals consented to enrollment. More than half (N = 10) believed that they were at no or low future suicide risk after discharge. Participants who felt that their future risk for suicide was low or none were significantly older (mean 59.3 yr, SD: 8.3) and reported significantly less severe suicidal ideation in the past month (mean CSSR-S 2.5, SD 2.1) compared to those participants who believed that their future risk was high (mean age 47.5, SD: 8.6; mean CSSR-S 4.7, SD 0.5, p < 0.05). However, all participants had a lifetime history of severe suicidal ideation (mean CSSR-S > 4.7). Many participants felt that peers facilitated treatment engagement. However, participants expressed a tendency to avoid treatment if they experienced unwanted side effects, encountered stigma, or experienced poor-therapeutic alliance. Five participants experienced poor continuity of care after discharge. Of these participants, four reported at the time of discharge no or low perceived future risk of suicide and three were readmitted within 90 d after discharge.

Conclusions:

Individuals may not appreciate that they are at heightened risk for suicide after hospitalization and this may negatively impact treatment engagement.

Contributions of Health Care to Longevity: A Review of 4 Estimation Methods

PURPOSE

Health care expenditures and biomedical research funding are often justified by the belief that modern health care powerfully improves life expectancy in wealthy countries. We examined 4 different methods of estimating the effect of health care on health outcomes.

METHODS

We reviewed the contributions of medical care to health outcomes using 4 methods: (1) analyses by McGinnis and Schroeder, (2) Wennberg and colleagues' studies of small area variation, (3) Park and colleagues' analysis of County Health Rankings and Roadmaps, and (4) the RAND Health Insurance Experiment.

RESULTS

The 4 methods, using different data sets, produced estimates ranging from 0% to 17% of premature mortality attributable to deficiencies in health care access or delivery. Estimates of the effect of behavioral factors ranged from 16% to 65%.

CONCLUSIONS

The results converge to suggest that restricted access to medical care accounts for about 10% of premature death or other undesirable health outcomes. Health care has modest effects on the extension of US life expectancy, while behavioral and social determinants may have larger effects.

DTEXT - text messaging intervention to improve outcomes of people with type 2 diabetes: protocol for randomised controlled trial and cost-effectiveness analysis

BACKGROUND

Diabetes prevalence is rapidly increasing, with type 2 diabetes predicted to be the leading contributor of non-communicable disease in Australia by 2020. It is anticipated that rates of type 2 diabetes will continue to increase if factors such as overweight and obesity, low physical activity and poor nutrition are not addressed. The majority of Australians with type 2 diabetes do not meet the guidelines for optimal diabetes management, and access to diabetes education is limited. This highlights the need for new interventions that can reduce existing barriers to diabetes education, attain greater population reach and support self-management strategies for people with type 2 diabetes. Mobile phone text messages have shown promising results as an intervention for people with chronic disease. They have the ability to achieve high levels of engagement and broad population reach, whilst requiring minimal resources. There is however, no evidence on the effect of text messaging to improve the health of people with type 2 diabetes in Australia.

METHODS/DESIGN

This randomised controlled trial aims to investigate if a 6 month text message intervention (DTEXT) can lead to improvements in glycated haemoglobin (HbA1c) and diabetes self-management among Australian residents in New South Wales (NSW) with type 2 diabetes. Community dwelling adults (n = 340) will be recruited with the primary outcome being change in HbA1c at 6 months. Secondary outcomes include behaviour change for diabetes self-management, self-efficacy, quality of life and intervention acceptability. An economic evaluation will be conducted using a funder plus patient perspective.

DISCUSSION

This study will provide evidence on the effectiveness and cost effectiveness of a text message intervention to reduce HbA1c and enhance self-management of type 2 diabetes in the Australian population. If successful, this intervention could be used as a model to complement and extend existing diabetes care in the Australian health care system.

TRIAL REGISTRATION

The study has been registered with the Australian New Zealand Clinical Trials Registry, Trial ID: ACTRN12617000416392 . Registered: 23 March 2017.

Translating behavioral medicine evidence to public policy

Behavioral medicine has made significant contributions to our understanding of how to prevent disease and improve health. However, social and environmental factors continue to have a major influence on health in ways that will be difficult to combat on a population level without concerted efforts to scale interventions and translate the evidence into public health policies. Now is also the right time to increase our efforts to produce policy relevant research and partnerships that will maximize the chances that our evidence is taken to scale in ways that can influence population health broadly, and perhaps contribute to the reduction of the recalcitrant health disparities that plague virtually every area of behavioral medicine focus. As a field we must take an active role in policy translation, learning from the public policy and political science disciplines, and our own pioneers in policy translation. This article discusses importance of accelerating evidence translation to policy, and suggests several factors that could enhance our translation efforts, including embracing policy translation as a key goal in behavioral medicine, increasing our understanding in variability of evidence-based policy adoption across and within states, improving our understanding of how to most effectively communicate our findings to policy makers, conducting research that is responsive to policy makers' needs, and considering the important role of local policy partnerships.

Relationships Matter: Progress and Challenges in Research on the Health Effects of Intimate Relationships

Social connections play an important role in health and disease and provide opportunities for clinical and public health interventions. Marriage and similar intimate relationships play a central role in the potential health benefits of positive social connections. This editorial provides an integrative perspective on three papers in this issue of Psychosomatic Medicine that examine intimate relationships and health and illustrates the application of current areas in relationship science. The importance of integrated conceptual models and statistical techniques to disentangle common third factors and overlapping constructs are highlighted, as well as the need for a multi-method approach that goes beyond self-report questionnaires. This editorial concludes with a summary of biobehavioral and psychological mechanisms and directions for future research.

Physical Activity, Screen Time, and Dietary Intake in Families: A Cluster-Analysis With Mother-Father-Child Triads

Background: The co-occurrence of multiple health behaviors such as physical activity, diet, and sedentary behavior affects individuals' health. Co-occurence of different health behaviors has been shown in a large number of studies. This study extended this perspective by addressing the co-occurrence of multiple health behaviors in multiple persons. The objective was to examine familial health behavioral patterns by (1) identifying clusters of families with similar behavior patterns and (2) characterizing the clusters by analyzing their correlates.

Methods: Cross-sectional data were collected from 198 families (mother, father, and child). Mothers, fathers, and children completed questionnaires assessing health related behaviors (physical activity, consumption of “healthy” and “unhealthy” foods, and screen time), the perception of Family Health Climate (regarding physical activity and nutrition) and demographics. Twelve variables (four health behaviors of three family members) were included in a cluster analysis conducted with Ward's Method and K-means analysis. Chi-square tests and analyses of variance were performed to characterize the family clusters regarding their demographics and their perception of Family Health Climate.

Results: Three clusters of families with specific behavioral patterns were identified: “healthy behavior families” with levels of physical activity and consumption of healthful foods above average and levels of media use and consumption of sweets below average; “unhealthy behavior families” with low levels of consumption of healthful foods and high levels of screen time; “divergent behavior families” with unhealthier behavioral patterns in parents and healthier screen time and eating behaviors combined with low physical activity levels in children. Family Health Climate differed between family clusters with most positive ratings in “healthy behavior families” and least positive ratings in “unhealthy behavior families.” “Divergent behavior families” rated the nutrition climate nearly as high as “healthy behavior families” while they rated the physical activity climate nearly as low as the “unhealthy behavior families.”

Conclusions: The study shows that co-occurrence of multiple health behaviors occurs on the family level. Therefore, focusing the family as a whole instead of individuals and targeting aspects related to the Family Health Climate in interventions could result in benefits for both children and adults and enhance effectivity of intervention programs.

Realizing the full potential of precision health: The need to include patient-reported health behavior, mental health, social determinants, and patient preferences data

Precision health and big data approaches have great potential, yet such benefits will be realized only when social and behavioral determinants of health and patient preferences are combined with genomic information. Literature review and co-author experiences informed this commentary. Validated health behavior, mental health, and patient preference measures were collected and summarized in real time. Integration of such data into existing data sets will advance precision health, patient-centered care, research, and policy.

Lack of interest in physical activity - individual and environmental attributes in adults across Europe: The SPOTLIGHT project

A considerable proportion of European adults report little or no interest in physical activity. Identifying individual-level and environmental-level characteristics of these individuals can help designing effective interventions and policies to promote physical activity. This cross-sectional study additionally explored associations between level of interest and physical activity, after controlling for other individual and environmental variables. Measures of objective and perceived features of the physical environment of residence, self-reported physical activity and other lifestyle behaviors, barriers towards physical activity, general health, and demographics were obtained from 5205 European adults participating in the 2014 online SPOTLIGHT survey. t-Tests, chi-square tests, and generalized estimating equations with negative binomial log-link function were conducted. Adults not interested in physical activity reported a higher BMI and a lower self-rated health, were less educated, and to a smaller extent female and less frequently employed. They were more prone to have less healthy eating habits, and to perceive more barriers towards physical activity. Only minor differences were observed in environmental attributes: the non-interested were slightly more likely to live in neighborhoods objectively characterized as less aesthetic and containing more destinations, and perceived as less functional, safe, and aesthetic. Even after controlling for other individual and environmental factors, interest in physical activity remained a significant correlate of physical activity, supporting the importance of this association. This study is among the first to describe characteristics of individuals with reduced interest in physical activity, suggesting that (lack of) interest is a robust correlate of physical activity in several personal and environmental conditions.